Gynecology is not generally thought of as an ASC standby, but it doesn’t have to be that way. Here’s what experts have to say about bringing the specialty into your facility.
1. Gynecology is well-suited to the ASC setting.
Gynecology procedures are a perfect match for ASCs, says Pat Alagia, MD, former director of minimally invasive gynecological surgery at George Washington University Hospital and current president of Safe Sedation, an anesthesia services provider.
“Endometrial ablations, hysteroscopy, bladder neck extension, reconstruction of the pelvic floor, sterilization, procedures for uterine bleeding, fibroids, ovarian cysts, D&Cs — these high-throughput procedures can be easily done in the ASC,” he says. “A lot of the devices being used in hospital ORs can be used in the ASC; the technology for the procedures has replaced a lot of the techniques, making Gynecology well-suited to the outpatient setting.”
2. Gynecology is trending out of hospitals.
Increased use of global endometrial ablation (GEA) devices, uterine artery embolization (UAE) devices, hysteroscopes and endometrial resection devices for minimally invasive hysterectomy alternative procedures will drive large growth in the minimally invasive gynecology market, according to Global Markets for Hysterectomy Alternatives 2008. The report, produced by Millennium Research Group, a leading provider of strategic information to the healthcare sector, highlights six trends:
• The global hysterectomy alternatives market will generate more than $700 million in 2012, primarily driven by expanding GEA procedure volumes. In the United States, this is expected to increase the market value of GEA devices from about $300 million in 2006 to about $550 million in 2012.
• The number of GEA procedures performed in physician offices and ASCs will continue to expand over the next five years because reimbursement levels for the procedures in these settings make these treatments lucrative for physicians. “The availability of a sufficient level of reimbursement has facilitated gynecologist adoption of GEA and, as a result, the procedure has become the gold standard for treating menorrhagia, an abnormally heavy menstrual period,” says the report.
• The UAE segment — “comprising microspheres, PVA particles and embolization coils” — will also expand due to demand for its efficacy treating fibroids and its minimally invasive nature; however, an inefficient referral process between “gynecologists, who generally manage patients suffering with uterine fibroids, and interventional radiologists, who perform the UAE procedures,” is a challenge.
• The use of endometrial resection will decline in the United States in favor of lessinvasive treatments. “Adoption of procedures such as GEA and UAE will cannibalize endometrial resection procedures through 2012,” says the report.
• Hysterscope use will increase with the growth in popularity of hysteroscopic procedures, such as transcervical female sterilization. The demand, especially for rigid versions of the scopes, but for the flexible versions as well — “because the superior image quality afforded by these devices enhances diagnostic capabilities” — will drive up the value of the U.S. market to about $40 million annually in 2012. However, the high cost of the devices remains a challenge in adoption of the technology.
• Over the next five years, it is predicted that the “number of alternative procedures for menorrhagia will experience strong single-digit growth, while alternative procedures to treat uterine fibroids will grow until they surpass the number of hysterectomies performed for the same condition.”
ASCs must position themselves to take advantage of these trends, say experts.
3. Gynecology physicians are looking for opportunities.
“The average age for an OB to stop practicing is 47 years old, and they’re saying, ‘What else can I do?’” says Dr. Alagia. “Malpractice rates can halve when you stop practicing obstetrics, so a lot of OB/GYNs start to just do gynecology. They realize practicing in the hospital is not as economically as viable as doing these in the office or ASC; the natural transition is to the ASC, where they can bring volume and have part-ownership.”
If a physician chooses to maintain practice in obstetrics, there are two key barriers to overcome in order to bring gynecology physicians into your center.
First, there is the nature of the specialty. If a woman is in labor at the hospital, she can’t wait, says Mike Lipomi, MSHA, president of RMC MedStone Capital. As a result, OB/GYNs tend to schedule their elective procedures at the hospital, to ensure they are nearby.
“Still, they usually get enough notice to finish outpatient cases they’re doing,” says Mr. Lipomi.
Therefore, if your ASC is in close proximity to the hospital, it will be a more attractive option than if it’s across town, and you should play that up.
“And if they’re in a group of, say, five OB/GYNs, they can organize the practice so that someone is handling deliveries on a given day, while another is able to do a lineup of laparoscopies at the ASC,” says Mr. Lipomi. “It’s a bit harder to work around if they’re in solo practice.”
Second, says Mr. Lipomi, “The fact that obstetrics are hospital-based is a concern; physicians have to maintain a relationship with the hospital facility.” He recommends gauging the atmosphere in your area before making a move that might damage your facility’s or the physician’s relationship with the hospital.
Beyond that, recruitment should be a snap, says Dr. Alagia.
“The time management aspects of the ASC will appeal to physicians who have been largely hospitalbased: 15 minutes between procedures versus 45, it’s easy to see the benefit,” he says. “ASCs just need to go to gynecologists, show them how the economics work, and they’ll respond accordingly.”
4. Adding gynecology is a smooth transition.
“The beauty of gynecology is that it’s not super-specialized like orthopedics; you can easily do it if you’re already doing ENT, general or urology,” says Dr. Alagia. “And your patient mix is going to be younger women of child-bearing age, so their co-morbidities are going to be very low. The procedures are low-acuity and rapid-turnover, like GI. These factors make it a great way to diversify your payor mix.”
Lisa Austin, RN, vice president of operations with Pinnacle III, offers this advice to ensure smooth integration of gynecology into an ASC.
“When considering staff needs, it is imperative to empower the decision to bring this specialty in the mix: Involve the surgeon and all equipment vendors in in-servicing and documentation of competency for the staff,” she says. “It is best to start with minimally invasive procedures such as ablation and diagnostic hysteroscopy. When adding laparoscopic procedures, ensure you have equipment and instruments to handle emergency situations. Gynecology procedures can sometimes develop into emergent situations. The greater complexity of the case, the earlier the case should be scheduled.”
5. Gynecology can be done profitably.
“A busy gynecologist will do a few hundred ASC-suited elective cases a year, so you’re looking at the possibility of fairly significant facility fees,” says Dr. Alagia. “And the patient base is mostly comprised of younger women with commercial insurance, which makes it an economically sound proposition.”
As long as you carefully consider a few key areas, says Ms. Austin, these procedures can be done profitably.
First, she says, “When purchasing new equipment, look to trial for a length of time that lets the surgeon determine specific needs and usability of equipment. Also, bargain on any disposables that you know will be high-volume supplies. If your ASC is part of a large organization with many facilities, look to share supplies for low-volume, high-dollar supplies that require bulk purchase or network with other ASCs through your vendors for supplies that other ASC’s may want to sell if no longer performing procedures.”
Second, as mentioned, start with minimally invasive procedures. “Doing large volumes of these will promote efficiencies, resulting in profitability,” says Ms. Austin.
Third, she says, “Evaluate your managed care contracts to ensure sufficient reimbursement before starting new procedures. Consider negotiating carve outs for the low-volume, high-complexity cases,” just as you would for orthopedics.
Finally, ensure gynecology physicians, who may be used to the hospital, understand the mindset of the ASC: “Make sure they know the fast pace that exists in ambulatory surgery, and how key that is to the cost-effectiveness and the time efficiencies we realize in this setting,” says Ms. Austin.